In simple words: This code represents a follow-up visit for a broken left forearm bone (radius) that went through the skin. The bone is broken diagonally across the shaft and did not heal correctly, which means it is now crooked or misaligned. The break is classified as a severe open fracture (Type IIIA, IIIB, or IIIC).

This code describes a non-displaced, oblique fracture of the left radius shaft. It is used for a subsequent encounter after the initial treatment of an open fracture classified as type IIIA, IIIB, or IIIC according to the Gustilo classification. The fracture has resulted in malunion, meaning the bone has not healed properly, resulting in a deformity or abnormal alignment.

Example 1: A patient initially sustained an open fracture of their left radius in a motorcycle accident, which was classified as Gustilo type IIIB. The fracture was treated surgically with internal fixation. The patient is now being seen for a follow-up appointment and the physician notes that the fracture has healed with malunion. Code S52.335R is used., A patient was previously treated for a severe open fracture of their left radius (Gustilo IIIA) after a fall. They present to their orthopedic surgeon for a follow-up visit several months later. Imaging reveals the bone has healed in a malaligned position, confirming malunion. Code S52.335R is used., A patient is seen in the clinic for persistent pain and limited range of motion in their left forearm following a Gustilo type IIIC open radius fracture. Imaging studies confirm malunion of the fracture. As this is a subsequent encounter, S52.335R is used.

Documentation should include details of the initial injury, the type of open fracture (IIIA, IIIB, or IIIC), the treatment provided, evidence of malunion based on physical exam and imaging studies (e.g., X-ray, CT scan), and the current symptoms or complaints of the patient.